The breasts can vary in size and shape and may be uneven. The UCSF note that people should wait for approximately 1 year before considering breast augmentation surgery. A person can expect fat to collect around their hips and thighs. Muscle mass and strength will decrease. Additionally, arms and legs will appear smoother. This is because the fat below the skin becomes thicker. Facial hair, and hair on the chest, arms, and back, will grow at a slower rate. However, it will not stop growing entirely.
According to a article , a person can expect a decrease in sexual desire and function within 1—3 months. However, these changes can take 3—6 years to reach their maximum effect. A systematic review found that estrogen hormone therapy positively affects the emotional and mental health of transgender individuals.
The UCSF state that a person may notice that they experience a wider range of emotions. They may also develop different tastes and interests.
These emotional changes should settle. During this time, some people might find it helpful to talk to a mental health professional to help explore and understand these new emotions and thoughts. Once a person starts taking estrogen hormone therapy, they may begin to experience erectile dysfunction and fewer erections. However, a person will still be able to reach orgasm. If a person is concerned about maintaining an erection, they can talk with a healthcare professional about taking medications, such as Viagra sildenafil.
This can occur 3—6 months after beginning estrogen hormone therapy. Although there is a decrease in testicle volume, the amount of scrotal skin does not change. If a person decides to undergo gender-affirming surgery, the surgeon will use the scrotal skin to create the labia majora. Anecdotally, some transgender women note that their orgasms feel different once they begin estrogen hormone therapy.
Studies have investigated the effect of estrogen hormone therapy on the reproductive system. However, the results are not clear. A systematic review notes that in some cases, estrogen hormone therapy causes infertility, whereas, in others, it does not. In most cases, people regain fertility once they stop taking the hormones.
However, there is some evidence that the longer a person takes estrogen hormone therapy, the less likely they are to have fertile sperm. People may take into account several considerations before deciding to use estrogen hormone therapy. A systematic review suggests that transgender women may have an increased risk of heart disease and bone loss.
Hormone therapy for transgender women is intended to feminize patients by changing fat distribution, inducing breast formation, and reducing male pattern hair growth Estrogens are the mainstay therapy for trans female patients.
Through a negative feedback loop, exogenous therapy suppresses gonadotropin secretion from the pituitary gland, leading to a reduction in androgen production Estrogen alone is often not enough to achieve desirable androgen suppression, and adjunctive anti-androgenic therapy is also usually necessary. Ethinyl estradiol used to be the mainstay of most estrogen-directed therapies. This is no longer the case, as clinical evidence has showed a strong relationship between ethinyl estradiol and the incidence of deep venous thrombosis As a result, there are strong recommendations against the use of ethinyl estradiol in transgender patients 8.
See Table 2 for dosing recommendations. No studies have examined the efficacy of the different formulations specific to transgender hormone management.
After the age of 40, transdermal formulations are recommended as they bypass first pass metabolism and seem to be associated with better metabolic profiles There are no unanimous recommendations for the use of anti-androgens.
Options are also listed in Table 2. Spironolactone is one of the most common medications used to suppress endogenous testosterone in trans female patients. The biggest risk associated with spironolactone is hyperkalemia, and this should be closely monitored. GnRH agonists can be very expensive, and are not always a good option for patients. Progestins are used by some providers, but should be used with caution as there is a theoretical risk of breast cancer associated with long-term exogenous progesterone use Many trans men seek maximum virilization, while others desire suppression of their natal secondary sex characteristics only.
Within three months of initiating testosterone therapy, the following can be expected: cessation of menses amenorrhea , increased facial and body hair, skin changes and increased acne, changes in fat distribution and increases in muscle mass, and increased libido 11 , Later effects include deepening of the voice, atrophy of the vaginal epithelium, and increased clitoral size.
Male pattern hair loss also can occur over time as a result of androgenic interaction with pilosebaceous units in the skin Some patients find this favorable as it may be considered masculinizing. However, patients should be made aware of the potential side effects on sexual functioning that can be associated with these medications, and they should be counseled that no data exist on the use of these medications in transgender men In most female-to-male patients unless testosterone is administered during the peri-pubertal period , there is some degree of feminization that has taken place that cannot be reversed with exogenous testosterone.
As a result, many transgender men are shorter, have some degree of feminine subcutaneous fat distribution, and often have broader hips than biologic males The following changes are expected after estrogen is initiated: breast growth, increased body fat, slowed growth of body and facial hair, decreased testicular size and erectile function. The extent of these changes and the time interval for maximum change varies across patients and may take up to 18 to 24 months to occur.
Use of anti-androgenic therapy as an adjunct helps to achieve maximum change. Longitudinal studies also show positive effects on sexual function and mood 16 , There is biologic evidence that may explain this. Kranz et al. SERT expression has been shown to be reduced in individuals with major depression These types of data are preliminary, but do point to the important role of hormone therapy in patients who suffer from gender dysphoria.
Hormone therapy may even have a positive effect on physiologic stress as well. Colizzi et al. They found that after starting cross-sex hormones, both perceived stress and cortisol were significantly reduced. This finding also has important implications for treatment. Patients on testosterone should be monitored every 3 months for one year and then every 6 to 12 months thereafter. Hormones should be carefully monitored to avoid a prolonged hypogonadal state if dosing is too low, which can lead to significant losses in bone mineral density; and to avoid exposures to supraphysiologic levels, which could have significant physiologic and metabolic effects Sex steroids—testosterone and estradiol—are necessary to maintain bone health in men and women, respectively.
They are responsible for bone growth and turnover, and hypogonadal states in both males and females can result in clinically significant bone loss. Testosterone has a direct role in bone health maintenance, but the steroid is also aromatized peripherally to estradiol, which has a very important role as well Testosterone also has an important role in increasing muscle mass, which further helps with bone health preservation.
Studies have looked at bone health in transgender men on long-term testosterone therapy. Exogenous testosterone appears to have an anabolic effect on cortical bone and when dosed at physiologic levels, is adequate enough to avoid issues with bone demineralization in transgender patients Transgender women may be at higher risk for bone loss despite estrogen use This is likely a result of anti-androgen use, and therefore, providers should consider stopping anti-androgen therapy if and when patients undergo orchiectomy with or without genital confirmation surgery.
Screening for bone loss should be performed per the guidelines for the general population, unless a patient has baseline low bone mineral density, or is at risk for osteoporosis tobacco use, alcohol abuse, previous fractures, eating disorder, family history of osteoporosis. Patients at risk should be screened sooner and more regularly. It is not clear whether use of exogenous testosterone increases the risk of cardiovascular disease in transgender men.
Some studies have shown that testosterone has a negative effect on indices that may increase the risk of cardiovascular events. For instance, Gooren and Giltay 28 showed that long-term testosterone use reduced high-density lipoprotein cholesterol and increased triglycerides as well as inflammatory markers.
Other studies have found similar changes. Wierckx et al. Despite these metabolic changes, and negative impact on potential risk factors for cardiovascular disease, no studies have found an increase in the occurrence of cardiovascular events such as myocardial infarction, deep vein thrombosis, and cerebrovascular events 16 , 29 , Studies looking at the effects of estrogen on cardiovascular disease in transgender women are not very conclusive, but do show that there may be a trend toward an increased risk of heart disease, which should be further studied.
Use of oral ethinyl estradiol appears to be strongly associated with cardiovascular events 30 and should therefore be avoided as a mainstay therapy for patients In addition, diabetes is a significant risk factor for cardiovascular disease and may have an important role in raising the risk of cardiovascular morbidity in trans women on estrogen, as this comorbidity has been found to be prevalent among the transgender population Large-scale prospective studies are lacking. Many of the studies that currently exist have small patient numbers as well as short or medium-term follow-up, and very few of the patients studied are over the age of Furthermore, no head-to-head comparisons of hormone regimens have been published.
It is therefore, not possible to draw definitive conclusions about the adverse effects of long-term cross-sex hormone use. Routine laboratory monitoring of patients on cross-sex hormone therapy can be challenging because results are often reported using gender-specific reference intervals, which are not all appropriate for transgender patients. The face and eyes also look more feminine as the fat shifts or increases. It may take a few years to develop, which is why it is better to wait at least two years before you take any drastic feminization steps via procedures.
The hair on the body, including arms, back, and chest will grow less thick. Their growth will also slow down with time. Facial hair will also grow slower and thin out. However, it will not go away completely without laser treatments and electrolysis. Changes in the emotional state vary according to the person.
The transition is often similar to puberty and feels like a roller coaster. You may feel like you are experiencing more feelings or emotions and even developing different pastimes, tastes, interests, and behavior in relationships. If these changes are affecting the quality of life then we generally will discuss reducing dose of Estrogen.
Some people may need supportive psychotherapy during these changes. After beginning Estrogen Hormone Therapy, you will notice that the number of erections you experience has lessened. It may also not be firm enough or last long enough to penetrate. However, you will be able to experience orgasms and even have erotic sensations. Some people also find that different parts of the body and sex acts are pleasurable now.
Orgasms can have less peak intensity and begin to feel as though they impact the whole body rather than just the genitals. Your doctor can help you weigh the risks and benefits. Feminizing hormone therapy is used to alter your hormone levels to match your gender identity. Typically, people who seek feminizing hormone therapy experience discomfort or distress because their gender identity differs from their sex assigned at birth or sex-related physical characteristics gender dysphoria.
To avoid excess risk, the goal is to maintain hormone levels in the normal range for the target gender. If used in an adolescent, hormone therapy typically begins at age Ideally, treatment starts before the development of secondary sex characteristics so that teens can go through puberty as their identified gender. Many trans girls are treated with a medication to delay the start of puberty.
Gender affirming hormone therapy is not typically used in children. Feminizing hormone therapy isn't for all trans women. Your doctor might discourage feminizing hormone therapy if you:.
Talk to your doctor about the changes in your body and any concerns you might have. Complications of feminizing hormone therapy might include:. Because feminizing hormone therapy might reduce your fertility, you'll need to make decisions about future childbearing before starting treatment. The risk of permanent infertility increases with long-term use of hormones, especially when hormone therapy is initiated before puberty.
Even after stopping hormone therapy, testicular function might not recover sufficiently to ensure conception without reproductive technology assistance.
If you want to have biological children, talk to your doctor about freezing your sperm sperm cryopreservation before beginning feminizing hormone therapy.
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